Is there such a thing as too much dialysis such as doing 10 hr. txs as opposed to 8 hr txs? I have read that dialysis strips out vitamins and minerals etc., but with nocturnal dialysis one is eating so much better so does it balance out?
Jane, one of the nephrologists I know who is a long-time home dialysis advocate has told me, “you can never have too much sex or too much dialysis.” Okay, he’s a character, believe me. But when you consider that healthy kidneys work 24/7, anything less than that can’t be “too much.”
That said, it IS possible to remove too much fluid. As far as vitamins and such, it’s important to keep track of the levels and replace anything that is getting deficient.
Jane, you will need supplements/vitamins…it takes sometime till they figure out how much you need.
In a sense…my opinion, too much dialysis is possible…for example, if labs show a KTV above normal and your dialyzing 4 hours and Dr. says you are elegible to cut down treatment time to 3 hours, would you?
I would hope that patients would think twice before cutting their time. Remember that the National Kidney Foundation K/DOQI guidelines have a recommended minimum Kt/V of 2.0. We keep having to remind people that this is the floor…not the ceiling. We don’t know what the ceiling is. Like Dori, I have heard from doctors who have been practicing for 30 or more years there is no such thing as too much dialysis.
In fact, I don’t put a lot of faith in Kt/V and here’s why. The United States Renal Data System 2005 Annual Data Report states that in 1998 the number of dialysis patients with the minimum Kt/V of 2.0 was 80% and the annual mortality rate for dialysis patients was 21.54%. In 2003 the number of patients with a minimum Kt/V of 2.0 was 91% and the annual mortality rate was 21.07%. If Kt/V and the rest of the clinical indicators that the renal community has worked so hard to changes and have in fact improved made that much difference, I’d have expected the mortality rate to drop more than 0.44%.
I’m not quoting these statistics to scare anyone, but to tell you that you hold your future in your hands. If a certain amount of dialysis takes you to the floor (which provides replacement of about 15% kidney function), wouldn’t you want to have your blood cleaned better than that to increase your chance of survival and of living a better life?
Like Beth, I don’t put much faith in Kt/V–because it is based on clearance of urea, a small molecule that freely diffuses between cell membranes, unlike pretty much any other molecule in the body. The most recent K/DOQI Guidelines for hemodialysis adequacy (which, Beth points out, is a minimum) still uphold urea as a marker, which I believe is very unfortunate. Perhaps phosphorus would have been a better choice. At any rate, it’s pretty clear that with Kt/V, we’re not measuring the right thing, or at least not in the right way.
I would hope that patients would think twice before cutting their time. Remember that the National Kidney Foundation K/DOQI guidelines have a recommended minimum Kt/V of 2.0.
Although we try to keep up with the literature, this is one that got past us. We were told in several units that the rec. min, was about 1.3.
The United States Renal Data System 2005 Annual Data Report states that in 1998 the number of dialysis patients with the minimum Kt/V of 2.0 was 80% and the annual mortality rate for dialysis patients was 21.54%. In 2003 the number of patients with a minimum Kt/V of 2.0 was 91% and the annual mortality rate was 21.07%
Find this really hard to believe. Don’t know many in-center patients that have a kt/V anywhere near 2.0. We always had about 1.6-1.8. When we became more educated, we saw that staff was not setting the tx up correctly ( i.e. left drip chambers low, forgetting to set other peramiters ) which caused alarms to go off. When we double checked everything staff did, kt/V went up to 2.0 At first, we thought something was wrong with the labs, but when we consistently got 2.0 we attributed it to a correctly set up tx with no or few alarms.
it’s pretty clear that with Kt/V, we’re not measuring the right thing, or at least not in the right way
Can’t say we felt any better at 2.0 then at 1.6. Agree there must be a better way to measure.
It was late and I meant to type 1.2 for the minimum Kt/V. I didn’t realize I did this until I read Heather’s message. Sorry, Heather and everyone else. A Kt/V of 2.0 was the recommended Kt/V for PD patients until just recently when the K/DOQI guidelines reduced it because studies hadn’t found that patients with higher Kt/Vs in PD did better and patients were having to do daytime exchanges in addition to nighttime dialysis to each the Kt/V of 2.0. We’ll have to see how the change affects their survival and hospitalizations. All I can say is that reading data from clinics doing nocturnal and daily dialysis where Kt/V is higher and other toxins are removed that can’t be removed in conventional dialysis proves to me that 1) more dialysis is better and 2) we’re not measuring something that makes more of a difference than Kt/V.
What is the thinking on GFR rate and creatinine levels for someone on PD ,3x in center, SDD, ND
I just started on the Nxstage and for the first month my kt/v was .5 I run for two hours with 15 effluent, ff of 40 and run 6 days a week. Does this sound right to you all?
That sure sounds right, the KTV for daily-short is measured differently than that of 3x a week counterpart…read this thread I started awhile back.
I have to comment on Beth’s statistics. Those sound simular to the fact that when Ice cream sales go up, so do boating accidents. Statisticly speaking that is a fact. Do Ice cream sales have anything to do with boating accidents? No they don’t, it is the heat that is the common factor. Beth’s statistics trying to compare Kt/v to an annual mortality rate is in the same ball park. Does she take in to account the increase in patients each year. How about other factors that play a role in mortality? What about a low Kt/V for an extended period of time. I would not in any way say that those statistics back up an idea to not be concerned with your Kt/V. I actually find it very offensive. I myself have noticed a dramatic change in how I feel with a higher Kt/V. Some may not and I can hear what they are saying. But, I would have to wonder if you have a higher Urea count? wouldn’t that put stress on other organs and parts of your body. I would think that idealy you would want to get the best Kt/v possible. There are many factors that play a role in mortality and I don’t think anyone is trying to single out Kt/V as the only one. As someone mentioned Phophorous plays a role too, but I had a phophorous level over six for years. In time I will see the effects of that and I feel that Kt/v is maybe more in that ballpark…Also I do believe you can get to much dialysis. Dialysis pulls off more then just waste. Yoiu would need to be able to replace the good stuff. I agree that if you are knowledgable it could be done, but I think goes into the same argument about vegaterians. They say that they can get enough protein in a vegaterian diet. The only problem with that is it takes a very diverse list of food and in quantities that are not reasonable for the average diet. Like that I do not think if you get to much dialysis the average person would be able to replace what they needed…
I didn’t mean to offend anyone by what I wrote. My goal is to help people live as long and as well as possible and I see this group of folks as the most likely to do that.
The mortality statistics that I quoted are from the USRDS for all patients on dialysis in any stated year. It doesn’t matter how many patients there are…the rate is quoted as a number per thousand patients. You can translate this into a percentage by dividing by 1000. The data USRDS reports is adjusted by age, gender, race, ethnicity, primary diagnosis and how long the patient had been on dialysis. The data is compiled by epidemiologists at the University of Minnesota under a contract with Medicare. Their data is widely accepted to be accurate.
Actually the Kt/V data came from the ESRD Networks. When they reported that 80% of patients on dialysis in 1998 had a Kt/V at or above 1.2, it’s my understanding that this data was reported by clinics to the ESRD Networks. The same is true when I said that in 2003, 91% of patients had a Kt/V at or above 1.2.
When I reported the percentages of patients with adequate dialysis along with mortality rates, I didn’t mean to say that Kt/V is the only factor that influences mortality rates. I don’t much faith in Kt/V. I believe there are many factors, some of which are not collected nationally, that could contribute as much if not more to survival. In fact, Dori and I believe that physical and mental functioning are underappreciated as risk factors for poor outcomes in dialysis patients. Large studies have shown these factors predict mortality and hospitalizations at least as well as Kt/V. We think identifying at risk patients and treating them could improve survival rates. Try out one of these surveys at:
http://www.amIhealthy.com (registration required, darn it)
To calculate my KT/V for 6x a week my clinic multiplies the number by 3. Not sure exactly why, but I know that is what they do. Mine is about .74 before the adjustment over 2 after the adjustment. I do 24 liters with a ff of .33
home hemo 9/04
I’m attaching a slide from a presentation by Dr. Michael Rocco that you can find on this site under Professional Resources. It’s complicated, but what it shows is why the HEMO study (which tried to show a difference between a Kt/V of 1.2 and 1.4) failed–it’s simply not possible within the time constraints of 3 times a week short treatments to make enough of a difference in “adequacy” to affect patient outcomes.
I know that what we started talking about was whether there is any such thing as “too much dialysis” (I’d say no). But, to some extent, we’re really talking about the difference between adequate and optimal treatment. Part of what the upcoming KDEC (Kidney Disease Economics Conference, http://kdec.nephronline.com/) meeting hosted by Nephrology News & Issues is aiming to do is to define optimal care–and this is something the renal community desperately needs to do. Adequate is not enough.
I think Beth is going along the right path. My center puts too much into KT/V. I want to look at the whole picture. Both the physcial and mental state of pts. If you are in center 3 days a week and it says your KT/V is good can you still have other # that are high or low? And what is your mental out look on life. I’ve talked to pts ( in center) that don’t care what any of the #'s says. Going to the center is outing where you meet people in the same age more or less and go on about other things in life. In other words they have left having a just getting by life, for a better life or a great life. :?:
I still think there can be too much dialysis…I mean c’mon!! Your literally wiping out alot of nutrients/minerals! The way I see it is that if you do so much dialysis then you’ll be on a race to catch up with nutrients/minerals lost from every treatment!..Eventually you’ll see all these pills. supplemets in front of you…so basicly the way I see it is solely entirely on the individuals needs…some people may need longer runs all because of other underlying problems, others will only need to run short times because their labs look excellent…so lets say, if labs lookm excellenyt and you, feel great, now should we increase more time on dialysis? :roll: :roll:
It’s my understanding that patients that are doing daily and nocturnal dialysis are not as restricted in their diet as patients on in-center HD. In fact, I’ve read what people on NHHD are eating and see that it looks like a pretty normal diet. In addition, I suspect most patients are taking a vitamin and mineral supplement that may even be specially formulated for people on dialysis. If so, I suspect that what dialysis is removing is being replaced. However, talk with your dietitian.
Are you asking if someone should dialyze 24 hours a day if he/she feels well? In a sense, that is what CAPD patients are doing…it’s just that it probably isn’t removing enough wastes to be considered full replacement of kidney function. Eventually I hope that nanotechnology allows full replacement of kidney function through 24/7 dialysis or that stem cell research makes it possible to “fix” damaged kidneys so people don’t have to do dialysis or even have transplants. When that happens, you can look for me on a beach reading a book under an umbrella holding a drink with a cute little umbrella in it and you guys can join me there.
Yes - one of the best things about nocturnal is forgetting all the rules re: diet!! Only fluid intake to have to think about…all those things I’ve always liked - dried fruit, nuts, high potassium fruits - all back on the menu!
I take a mult-B with C; B6; Folic acid. No binders. No b.p. medication (altho it’s been up a bit lately) or anything else drug-wise. The blood figs are pretty good -pre/post done monthly show one or two things under the ‘human’ norm, post, but always over pre. So approx. 34 hours dx a week is working quite nicely. 8)
P.D. - yep, been there; done that. 5 exchanges a day…& for all intents & purposes I may’s well have been dead. A wasted year. So much better since being on haemo., especially nocturnal.
IT works! :lol: P.D. was a disaster for me, personally ,Gus. Crap clearances, weak as a kitten all the time. Sick as a dog. It was a good job the delivery guy had a trolley & used to drop the boxes off right in the room...coz I couldn't have moved them!! Whereas now, it's not too bad having to move stuff from the living room doorway into the dx room, as I have a certain amount of energy. Quite a lot really, on my good days. :)